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What is MALNUTRITION??
Case
• Baby Shanmuga Priya, 7 months old, weighing 4kg and length 58cms.
• Case of malnourishment
Indian and TN Scenario
• 65% of under 5 years children are malnourised• i.e 80 million (total population is 1.2 billion-
2011 census)• 10% of total 6.8million children are in the age
group of 0-6 years (6,80,000) out of which 30% are underweight (2,04,000)
Why Malnutrition??
sociodemographic factorsenvironmental factorsnutritional factors
Neglect to girl childLarge family sizeLack of child spacing and unplanned ma-ternity
Education of parentsSE statusSanitationStandard of livingPaternal attitudes towards chil-dren
Breastfeeding practisesDiet (normal and during illness)
classification
According to weight for age• GOMEZ’S classification• JELLIFFE’S classification
• WELCOME TRUST or INTERNATIONAL classification
• IAP classification
NUTRITIONAL STATUS WT for AGE (% expected)
Normal >90
First degree PEM 75-90
Second degree PEM 60-75
Third degree PEM <60
GOMEZ’S classification
NUTRITIONAL STATUS WT for AGE (% expected)
Normal >90
First degree PEM 80-90
Second degree PEM 70-80
Third degree PEM 60-70
Fourth degree PEM <60
JELLIFFE’S classification
WEIGHT for AGE OEDEMA CLINICAL TYPE OF PEM
60-80 + K
60-80 - UW
<60 - M
<60 + M.K
WT classification
NUTRITIONAL STATUS WT for AGE (% EXPECTED)
NORMAL >80
GD 1 PEM 71-80
GD 2 PEM 61-70
GD 3 PEM 51-60
GD 4 PEM <50
IAP classification
According to height for age
• WATERLOW’S classification• McLAREN’S classification
• VISWESHWARA RAO’S classification
HT for AGE (% EXPECTED
WATERLOW’S McLAREN’S VISWESHWARA RAO’S
NORMAL >95 >93 >90
FIRST DEGREE STUNTING
90-95 80-93 80-90
SECOND DEGREE STUNTING
85-90 - -
THIRD DEGREE
STUNTING
<85 <80 <80
According to weight for height• WATERLOW’S classification• McLAREN’S classification
WEIGHT for HEIGHT WATERLOW’S McLAREN’S
NORMAL >90 >90
MILD/FIRST DEGREE 80-90 85-90
MODERATE/SECOND DEGREE
70-80 75-85
SEVERE / THIRD DEGREE
<70 <75
WHO cut-off for assessment of malnutrition in community studies
CUT-OFF H/A W/H H/A & W/H
> MEAN – 2 SD
N N N
< MEAN – 2 SD
STUNTED WASTED STUNTED & WASTED
Standard deviation score (Z score)WHO classification
• ACUTE AND CHRONIC MALNUTRITION
W/A H/A W/H Interpretation
N N N N
N A.M
N C.M
A-on-C M
•MODERATE AND SEVERE MALNUTRITION
FEATURES MODERATE SEVERE
OEDEMA NO YES
WT-for-HT (WASTING)
70-79% <70%
HT-for-AGE (STUNTING)
85-89% <85%
• Calorie or protein intake• Time period• Adaptation• Free radical theory
Who can get marasmus or kwashiokor
Management of SAM (scu)
Diagnosis• Wt-for-Ht < 70% of expected
• Visible wasting• MAC <11 cm• Oedema
Guidelines by WHO for SAM treatment
General routine careEmergency treatment of shock and
anemiaTreat associated conditionsFailure to respond to treatmentDischarge before recovery is
complete
• HYPOGLYCEMIA treatmentConsious 50ml bolus of 10% glc by NG tubeUnconcious IV sterile 10% glc , 50ml of 10% glc by NG
tube
• HYPOTHERMIA treatment• DEHYDRATION treatment• ELECTROLYTE CORRECTIONNa NK, Mg YOedema NO DIURETICS
• INFECTION treatment
IV AMPICILLIN (50mg/kg/6hrly) + IV GENTAMICIN (2.5mg/kg/8hrly)IV CLOXACILLIN (100mg/kg/6hrly) if staph infection present
IV CEFOTAXIME (100mg/kg/8hrly)
IV CEFOTAXIME (200mg/kg/6hrly) + IV AMIKACIN ((15mg/kg/8hrly)
CIPROFLOXACIN (30mg/kg/day) in 2 doses {or}IV CEFTRIAXONE (50mg/kg/12 hrly) if baby is sick or already on
Nalidixic acid
• MICRONUTRIENT deficiencyMultivitamin suppliments
FA 1mg/dZINC 2mg/kg/dIRON 3mg/kg/d
• CAUTIOUS FEEDINGSmall, frequent, oral/NG tube feeds
Starter F-75 (75kcal/100ml + 0.9g protein/100ml)130 ml/kg/d of fluid (100 ml/kg/d if the child has severe
oedema) if the child is breastfed, encourage to continue breastfeeding
• ACHIEVE CATCH-UP GROWTHF-100 (100kcal + 2.9 g protein/100ml)
Increase 10ml in successive feeds, Wt gain >10g gain/kg/d
• EMOTIONAL SUPPORT• FOLLOW-UP
• EMERGENCY TREATMENT INSEVERE DEHYDRATION- RINGER LACTATE SOLUTION + DEXTROSE (5%)
and assess after 1 hr; worsening; septic shock improving; continue therapy start ORS if accepts orally
else wait till accept
SEVERE ANEMIA- Blood transfusion , oral iron
• Other associated causesVitamin A deficiency- vitamin A supplements (for eye sign)
and antibiotics with atropine (for corneal ulceration)
Dermatosis- zinc supplement (BARRIER cream)
Diarrhoea- metronidazole
Parasitic worms- mebendazole
TB- ATT therapy
• Failure to treatment• Discharge • Early discharge
RUTF
• Community approach to malnutrition• Palatable, high energy with adequate amount
of protein and minerals (similar to F100 but no water is added)
• Also addition of antibiotics is needed
RUTF INDIArice + green gram (paccapaiyiru)
• Calories 250.4g• Total Fat 6.7 g• Saturated Fat 0.8 g• Polyunsaturated Fat 3.7 g• Monounsaturated Fat 1.6 g• Cholesterol 0.1 mg• Sodium 354.7 mg• Potassium 213.6 mg• Total Carbohydrate 40.9 g• Dietary Fiber 2.8 g• Sugars 0.3 g
• Protein 6.1 g• Vitamin A 0.5 %• Vitamin B-12 0.0 %• Vitamin B-6 6.3 %• Vitamin C 0.5 %• Vitamin D 0.0 %• Vitamin E 8.9 %• Calcium 3.2 %• Copper 4.8 %• Folate 17.3 %• Iron 16.3 %• Magnesium 4.8 %• Manganese 31.9 %• Niacin 9.1 %• Pantothenic Acid 4.6 %• Phosphorus 5.8 %• Riboflavin 1.2 %• Selenium 12.8 %• Thiamin 13.4 %• Zinc 4.4%
Health promotion
• Of pregnant and lactating women (education and drugs)
• Promote breast feed• Low cost weaning foods• Nutrition education• Home economics• Family planning
Specific protection
• Diet of child (protein and energy rich like egg, milk, fruits etc)
• Immunization
Early diagnosis and treatement
• Survillance• Early diagnosis of infection
and diarrhoea & treatment• Rehydration of children in
diarrhoea• Supplementary food• Deworming of heavily
infected child
Rehabilitation
• Nutritional rehabilitation• Hospital treatment• Follow-up
• Promoting and adapting policies to fight malnutrition
• Providing resources to fight SAM
WHO, WFP, UNICEF and other patners support these campaigns
• National Nutrition policy• The integrated child development service scheme
TN against Malnutrition
• Budget for Nutrition and health highest in the country. (Rs.5719 crore for 11th plan)
• ICDS and PTMGRNMP (puratchi thalaivar MGR nutritious meal program) are best in country.
• 11th plan was for “malnutrition free state”• 12th plan (2011-16) had also same motive
RECALL
• Malnutrition• Causes• Classification• SAM• Community and national strategies towards
malnutrition
Thank You